The Price is Wrong: We Need to Solve the Healthcare Insurance Transparency Crisis

By Ashish Mandavia - You get an instant confirmation when you order groceries. You track your Uber as it turns the corner. You know the cost of a hotel room before you book it. These are the digital expectations on which we rely. Yet when it comes to our health, we remain in the dark. Read Full Article…

HVBA Article Summary

1. Lack of transparency fuels patient confusion and care delays: Despite advances in digital health access, outdated insurance processes and complex provider-payer contracts leave many Americans in the dark about coverage and costs. This opacity drives anxiety, surprise bills, and delayed care—especially among the nearly 60% of insured adults who face issues using their coverage.

2. Real-time insurance checks and cost estimates are key to trust: Empowering patients with upfront, automated verification of coverage and pricing—similar to booking travel—can reduce no-show rates, improve treatment adherence, and enhance both patient satisfaction and provider revenue. However, widespread adoption is stalled by legacy systems and misaligned incentives.

3. True reform needs consumer-first design, smart tech, and stronger policy: AI voice agents and empathetic digital tools can ease administrative burdens and educate patients, but systemic change depends on enforcing transparency regulations, restructuring payer incentives, and giving patients pricing clarity comparable to other industries.

Recent AI Policy Developments – Can Lessons be Learned from Telehealth Policy?

By Center for Connected Health Policy - Policymakers have typically been cautious about enacting extensive regulations around artificial intelligence (AI), but as AI becomes more common, meaningful policy changes have gradually been accelerating. CCHP is currently monitoring 94 pending policies at both the state and federal levels regarding AI and healthcare through its Telehealth Legislation and Regulation tracker. Most significant AI policy adoption has occurred at the state level thus far, and recent AI developments at the federal level continue to focus around a largely deregulatory approach to its use. Read Full Article…

HVBA Article Summary

1. Executive Order 14179 and OMB Reforms Signal Shift Toward AI Innovation: The Biden administration's EO 14179 aims to remove regulatory barriers to American AI leadership, directing agencies to develop an AI Action Plan and prompting the OMB to revise prior guidance. In response, new OMB memoranda (M-25-21 and M-25-22) prioritize innovation, public trust, and market competitiveness, emphasizing risk-managed, transparent AI adoption across federal agencies.

2. Federal Memos Promote Pro-Innovation and Competitive AI Procurement: OMB M-25-21 focuses on accelerating agency AI use through designated Chief AI Officers, interagency coordination, and governance for high-impact AI systems. OMB M-25-22 outlines procurement practices to foster competition, reduce vendor lock-in, and enhance cross-agency collaboration, while safeguarding taxpayer dollars and ensuring responsible deployment of AI solutions.

3. State-Level AI Policies Diverge, Highlighting Need for Consistency: States are developing their own AI frameworks—such as California's transparency laws for AI-generated patient communications and Indiana’s AI task force—creating a fragmented regulatory landscape. Drawing parallels to telehealth policy confusion, the article underscores the importance of harmonizing definitions and policies to reduce compliance complexity and protect patients in AI-integrated healthcare.

Trump looking at cutting US drug prices to international levels, sources say

By Patrick Wingrove - Drugmakers have been warned that the Trump Administration is considering linking U.S. medicine prices to lower amounts paid by other developed countries, according to two company sources who called the option the pharmaceutical industry's top concern. Both sources, who were not authorized to speak publicly, said they expected the policy to come from the agency that oversees Medicare and Medicaid health programs. Read Full Article…

HVBA Article Summary

1. Trump Administration Reconsiders Reference Pricing: The Trump Administration is exploring international reference pricing as a mid-level priority to reduce U.S. drug costs, a move industry insiders consider a major threat to pharmaceutical innovation. A pilot program through Medicare could be launched via the CMS Innovation Center, though operational and staffing challenges may hinder rollout.

2. Industry Pushback and Global Price Gaps: The pharmaceutical industry, led by trade group PhRMA, is lobbying against the policy, which it views as more alarming than tariffs. U.S. drug prices remain significantly higher than in peer nations—up to five times more—despite Medicare negotiations under the Inflation Reduction Act bringing some prices down.

3. Implementation Challenges and Strategic Risks: Experts warn that implementing reference pricing would require substantial CMS resources and face data limitations due to varying drug availability and undisclosed pricing abroad. Drugmakers might respond strategically by raising prices in reference countries to offset U.S. pricing pressure, potentially undermining the policy's intended cost savings.

Walgreens to pay $300 million in federal opioid settlement

By Kristen Smithberg - Walgreens has agreed to pay $300 million to settle federal prosecutors’ allegations that it illegally filled millions of invalid prescriptions for opioids and other controlled substances, the U.S. Justice Department said Monday. The money, plus 4% interest annually, will be paid out over six years under the terms of the agreement. Walgreens will also owe the U.S. an additional $50 million if the company is sold, merged or transferred prior to fiscal year 2032, the Justice Department said. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Government lawsuit alleges misconduct: A January lawsuit claims Walgreens violated the Controlled Substances Act by ignoring “red flags” on potentially illegal opioid prescriptions and then sought reimbursement through federal programs, potentially violating the False Claims Act.

2. Walgreens denies liability amid ongoing legal fallout: The company strongly disputes the government’s allegations, maintains its pharmacists prioritize patient safety, and stated in a regulatory filing that it does not anticipate further major opioid-related cases.

3. Broader opioid litigation context: Walgreens is part of a larger group of companies that have agreed to pay around $50 billion to settle opioid-related lawsuits, including its own 2022 settlement of up to $5.52 billion over 15 years, amid a crisis that has caused nearly 727,000 overdose deaths since 1999

High-deductible health plans should fight chronic disease harder, lawmakers tell IRS

By Allison Bell - Three House members are keeping up the fight to make the health savings account program friendlier to people who already have health problems. The lawmakers sent a letter asking the Internal Revenue Service to expand the list of chronic disease management items that an HSA-compatible "high-deductible health plan" can cover before the patient reaches the plan deductible. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Lawmakers push to expand HDHP chronic care coverage: A bipartisan group of House lawmakers is urging the IRS to expand the list of pre-deductible services for chronic disease management under IRS Notice 2019-45, aiming to make HSA-compatible High Deductible Health Plans (HDHPs) more accessible and beneficial for people with chronic conditions.

2. Support builds behind Chronic Disease Flexible Coverage Act: The proposed legislation, backed by Reps. Jason Smith (R-MO), Vern Buchanan (R-FL), and Jim Panetta (D-CA), would codify and expand the 2019 IRS guidance, enhancing HDHP flexibility and encouraging more workers—especially those with chronic conditions—to choose HDHP options.

3. Potential impact on employer-sponsored coverage: Expanding eligible pre-deductible services in HDHPs could help employers offer more attractive coverage to chronically ill employees, boosting enrollment in cost-effective, HSA-compatible plans and improving chronic disease management outcomes.

Trump Executive Order Demands More Transparency into PBM Compensation

By Remy Samuels - In an effort to lower prescription drug prices, President Donald Trump signed an executive order on Wednesday, which includes measures to improve transparency into pharmacy benefit manager fee disclosures. The executive order requires Secretary of Labor Lori Chavez-DeRemer to propose regulations pursuant to section 408(b)(2)(B) of the Employee Retirement Income Security Act to “improve employer health plan fiduciary transparency into the direct and indirect compensation” received by PBMs. Read Full Article…

HVBA Article Summary

1. Executive Order Targets Anti-Competitive Practices: The new executive order directs the Secretary of Health and Human Services to hold joint public listening sessions with officials from the Department of Justice, the Department of Commerce, and the Federal Trade Commission. These sessions will inform a forthcoming report with policy recommendations aimed at reducing anti-competitive behavior among pharmaceutical manufacturers and promoting greater fairness in the drug market.

2. FTC Spotlight on PBMs’ Market Control: The Federal Trade Commission has released two interim reports criticizing the “opaque” business practices of pharmacy benefit managers (PBMs), particularly the top three—OptumRx, Caremark, and Express Scripts—which together control nearly 80% of all U.S. prescriptions. The FTC noted these PBMs are vertically integrated across the drug supply chain and wield outsized influence over both the availability and pricing of prescription medications. The FTC also launched an administrative lawsuit against them in September 2024.

3. Push for Greater Medicare Drug Pricing Transparency: The executive order also instructs the Department of Health and Human Services to propose new guidance for the Medicare Drug Price Negotiation Program. The goal is to increase transparency in pricing decisions and prioritize negotiations on high-cost medications. This effort builds on the Biden-era initiative and contrasts with earlier Trump administration efforts, which issued several executive actions to reduce drug prices but achieved limited success.

The future of stand alone dental insurance: A Q&A with Sam Melamed

By Lily Peterson - The current state of the standalone dental insurance industry is currently undergoing a seismic shift, driven by emerging regulatory changes that stand to reshape market dynamics for insurers, brokers, and consumers. So says Sam Melamed, CEO of NCD, an award-winning dental & health insurance company. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Access and Target Markets for Stand-Alone Dental Plans: Americans without employer-based dental insurance typically access coverage by purchasing stand-alone dental plans, which range from basic preventive coverage to comprehensive plans with high annual maximums. These plans are especially well-suited for seniors on Original Medicare, gig workers, self-employed individuals, and those in non-benefits-offering jobs. Psychographically, they appeal to consumers seeking financial protection from costly dental procedures.

2. Regulatory and Market Forces Influencing Medicare Advantage Dental Benefits: Medicare Advantage dental benefits are directly influenced by carrier profitability and CMS regulations. When Medicare reimbursement rates tighten, plans often scale back dental benefits by reducing network size, lowering coverage amounts, or eliminating certain services. New CMS rules now also require plans to inform members of unused supplemental benefits midyear, potentially increasing costs and reducing embedded dental offerings further.

3. Outlook for Stand-Alone Market Growth and Regulatory Impacts: As embedded benefits in MA and ACA plans fluctuate, interest in stand-alone dental plans grows, particularly among seniors. New ACA rules allowing states to classify adult dental as an essential health benefit (beginning in 2027) could shift dynamics, though uptake depends on federal policy continuity. Meanwhile, Massachusetts’ dental MLR law has strained the individual plan market by forcing some carriers out and driving up rates due to high administrative costs.